By Dan Prendergast, M.A.
Mental health professionals and consumers of psychotherapy commonly talk about being for or against medication, and commonly talk about medical versus psychological variants of mental illness. I think this approach is problematic for a number of reasons, and today I would like to argue that we stop speaking in these terms because it negatively affects treatment decisions. First, speaking of psychological or biological forms of illness invokes a mind-body dualism that dates back at least to Descartes. I don’t buy in to this position since I (and probably most others) believe that mind and brain are essentially the same thing. Second, when we talk about biological and psychological forms of mental illness we fall into the common trap of confusing the causes of mental illness with the perspectives from which it is studied. A psychologist might be more likely to study cognitions, a psychiatrist might be more likely to study neurotransmitters, and individuals in other disciplines might study mental illness from sociological, historical, economic and political perspectives. However, this does not necessarily mean that a particular illness (e.g., depression) is always primarily caused by thoughts, neurotransmitters, or sociopolitical conditions. Third and most importantly, I think that making a distinction between “biological” and “psychological” forms of mental illness biases our treatment decisions towards biological or psychological interventions, and distracts us from which treatment(s) have the most supporting evidence.
A major concept in the study of mental health is that there are many routes to the same diagnosis, be it depression, anxiety, mania or psychosis. Within each diagnostic category there are probably many different subtypes that have yet to be understood (e.g., “there is not schizophrenia, there are schizophrenias”). For many disorders there are very clearly defined correlates and potential causes of illness that might involve thinking, brain structure, brain function, systemic physiological changes (e.g., thyroid problems, fever, drug use) or other causes, and I do not mean to suggest that these well researched findings are trivial, or that studying causes of mental illness is not critically important. What I would like to argue is that whatever the cause, in all forms of mental illness there are cognitive, behavioral, physiological and perhaps anatomical changes that occur together and negatively impact a person’s lived experience. Each of these represents an opportunity for intervention.
Once a person’s experience is distressing, mental health professionals must create a treatment plan featuring one or more appropriate interventions that reduce distress. Some of these treatment plans correspond well with presumed causes of mental illness, but most treatment plans probably do not. For example, if we knew that an individual’s depression happened to result from genetic factors we wouldn’t change their DNA, but might offer psychotherapy and a selective serotonin reuptake inhibitor. Another person might be depressed due to a thyroid problem, and might respond well to synthetic thyroid hormone and talk therapy that does not alter thyroid functioning. A third individual might be depressed following the death of a loved one and declaring bankruptcy, and treatment might involve medication and talk therapy but probably wouldn’t involve resurrection and transferring money to the client’s bank account. In my opinion (from a clinician’s perspective), once mental illness is present the most important question is what treatment can be most effective for a set of symptoms, almost regardless of what we believe the root cause of distress might be.
Earlier I wrote that we often confuse the diverse focuses commonly associated with different mental health disciplines for causes of illness. I would suggest that we take the different perspectives that are used to understand mental illness (biological, psychological, sociological, etc.) and reframe them as potential modes of intervention that are present for each client. To improve an individual’s experience, it is possible to facilitate change in behaviors, thoughts, brain structure, brain function, environment, or interaction with social services or other resources. Interventions for thoughts and behaviors typically involve psychotherapy, and interventions in brain functioning involve medications or other interventions. For some problems such as severe epilepsy, surgery to change brain structure is helpful. Changes in environment might include hospitalization or avoidance of certain people or situations. Still other individuals benefit from referrals to lawyers or public assistance programs. Many people benefit from more than one of these interventions. I think that the big question should be, “which interventions have the most support?”
This blog might be a bit long-winded and pedantic, but I think that drawing a distinction between the presumed cause of mental illness and its treatment serves clients and addresses barriers to treatment. For example, lets suppose that I am dealing with a depressed client. If I say, “I think that you have a biological depression,” the client might think that the serotonin functioning in their brain is hopelessly deficient, and might form a negative opinion of talk therapy. In reality we are probably not measuring the client’s serotonin levels, and there are probably people with similar serotonin functioning who are not depressed. I would rather tell this client that they appear to be quite depressed, and that medication that alters serotonin functioning has been strongly associated with reduced levels of depression for people with similar symptoms. For this hypothetical client, I am for medication. For other clients, my answer is that “it depends.” Perhaps I am making a picky point, but I think that the way we think and talk about issues related to treatment has a great influence on how we act.